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NEW 2021
Evaluation & Management
Coding and Documentation
Guidelines for Dermatology


  • Remote learning allows time-pressed surgeons and their staff stay abreast and ahead of coding issues without the cost or hassle of travel.
  • KZA experts present to you in the comfort of your home or office.
  • Quality KZA tools are downloadable, making implementation easy.


Evaluation & Management 2.0 Workshop
2021 E/M Guidelines for Dermatology

The Course

This 3-hour course analyzes the 2021 CPT E/M guidelines and presents them in the distilled understandable format for which KZA is known. Building on what providers are currently doing, the restructured elements of Medical Decision Making and Time are broken down and explained.

There will be “hands on” coding of E/M notes as well as plenty of time for Q&A.  Participants will have the opportunity to cement understanding and leave empowered with a “To Do List” for successful transition.

Documentation Tips

We will provide you with key documentation tips to optimize your coding and documentation. These tips can assist in building your electronic health record templates to adequately address the Medical Decision Making that takes place during an office visit. They will be used during the course to cement education points to prevent inadequate documentation.

Audit Tool

The audit tool is an edited version of the CPT guidelines restructured for easy use and education.  The course will use the tool to review notes and ‘score” them based on the MDM that is documented.

  • Gain a greater understanding of the overall 2021 changes to E/M, including the subtle nuances and reasons behind the revisions
  • Understand the revised times and Medical Decision Making processes for all office-based E/M codes starting Jan. 1, 2021
  • Learn what the performance of history and exam “only as medically appropriate” means
  • Learn what activities can be counted when selecting the level of service based on time for 2021 office-based services
  • Understand revisions to code descriptors for 99202-99215 and which codes have been deleted
  • Understand the role of ancillary staff with the “patients over paperwork” theme throughout the new coding process

Note: This course does not cover existing E/M guidelines which will be used, in 2021, for office consultation codes (9924x) and inpatient service codes.

Learning Objectives

  • Name three elements required for Medical Decision Making in 2021 for new and established patient visit Evaluation and Management (E/M) codes.
  • Differentiate Time ranges and requirements in the current and 2021 E/M guidelines.
  • Apply the correct guidelines depending on the category of E/M service.

*You will receive and initial confirmation email after registering and the login information for the meeting approximately 1 week in advance. Please email education@karenzupko.com if you have questions.

$499 per participant

The workshop content is copyrighted property of KarenZupko & Associates, Inc.  Any rebroadcast, reproduction, or other use of the pictures, content and accounts of this workshop or the accompanying handout without the express written consent of KarenZupko & Associates, Inc. is prohibited.


*agenda subject to change

15 minutes

Comparing Original to 2021 Guidelines for New & Established Outpatient Visits

  • Where did this new information come from?
  • Converting prior E/M code selection and guidelines to 2021 E/M code selection and guidelines
  • Key elements: Medical Decision Making and Time
  • What about History and Exam documentation?
  • Incorporating medical necessity into 2021 E/M documentation

95 minutes

2021 Using Medical Decision Making to Determine Level

  • Incorporating the Newly Redefined Medical Decision Making Elements
  • Element #1: Number and Complexity of Problems Addressed
    • Problems, Illnesses & Injuries: how are they defined?
    • Stable vs chronic
    • How is the complexity of the problem determined?
    • Counting the number of problems. What constitutes a separate problem?
    • Exercises: Determining number of problems in Dermatology
  • Element #2: Data to be Reviewed and Analyzed
    • Defining Data Category 1
      • What is included as an external note?
      • What is a unique data test?
      • What is a unique source?
      • Who qualifies as an independent historian and how is this role documented?
      • Exercises: Identifying unique tests and notes in Dermatology
    • Defining Data Category 2
      • Documenting independent interpretation
    • Defining Data Category 3
      • What constitutes a discussion of management or tests?
      • Who qualifies as an external or other source?
    • Exercises: Documenting unique tests and notes in Dermatology
  • Element #3: Risk of Complications and/or Morbidity or Mortality of Patient Management
    • Defining level of risk: what does CPT say?
    • Documenting level of risk. Do the current risk table examples still apply?
    • How do test and treatment decisions impact co-morbidity and risk?
    • Exercises: Determining level of risk in Dermatology
  • Documentation Tips by Element: Problems Addressed, Data Reviewed/Analyzed, and Risk

20 minutes

2021: Using Time to Determine Level of Service

  • What is included in the new ranges?
  • What work and whose work is counted when time is used?
  • Using Prolonged Service codes with time codes in 2021

30 minutes

Exercises: Documentation Review Using 2021 Guidelines

  • Auditing documentation with the new tool

15 minutes

Documentation Tips to a Successful Transition

5 minutes

Operational Steps to a Successful Transition


On-Demand Workshop

Sold Out Dates

November 5th at 2:00 PM CST Sold out!

November 17th at 12:00 PM CST Sold out!

December 12th at 7:00 AM CST Sold out!

February 25th at 1:00 PM CST Sold out!

March 6th at 10:00 AM CST Sold out!


Deborah Grider


Consultant and Speaker

Presented by

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